Secrets for Performance Improvement with Data‐Driven Practice Transformation
Jessica Henderson Boyd, MD, MPH
Chief Medical Officer
The Story
• Introduction to BMS
• Role of leadership
• Strategic alignment
• DRVS implementation
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Building trust in the data Workflow
Documentation Quality metric
Provider and staff engagement Translating data to patient care Results
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Baltimore Medical System
• Established in 1984 in Baltimore, MD
• 5 Health Centers, 7 School Based Health Clinics
– ~46,000 patients, ~140,000 visits
• 55‐60 clinical providers, 365 total staff
• FP, Peds, IM, OB/Gyn, BH
• Commitment to Quality
– The Joint Commission accredited since 1987
– Strategic plan for 2010‐2015: shift from volume‐focused 
quality‐focused culture
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Quality Plan 2013:
Elements of Quality
NPS
TJC
Patient
The Patient
Complaints
Experience
Model of
Care: PCMH
Accreditation
NCQA
QUALITY
Risk
Management
Quality
Indicators
Mortality
Reports
Incident
Reports
Competency
Credentialing
Peer Review
Support Staff Competency
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The Beginning
• BMS implemented an E.H.R. (Misys) in 2006
– Programmer on staff
– Manual audits  electronic reporting by 2009
• Each year, UDS report would be a “surprise” with data we didn’t believe
• Several ideas, processes, grants in place to improve health outcomes but no idea about how we were performing
• Reactive not proactive around performance • Next Step: Quality Program + HIT= Synergy!!
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A Change is Gonna Come
• 2011: Switch to new E.H.R. (NextGen)
– Reporting was a major factor in selection
• Dashboard, Report writer, Menu reports, Crystal Reports
• Reporting challenges
– Inconsistent
– Upgrades and changes in definitions = lots of work – Difficult to capture the information in the charts
• Unintended consequence of the switch?
– UDS: Back to manual audits for two years • Year 1: Data from two systems was difficult to integrate
• Year 2: Too many reports to develop and ensure accuracy; “UDS tool” was generic, regimented and focused on billing codes
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On the Road Again
• The switch to NextGen was the first step
– Significantly more capabilities
– More structured fields
• An external reporting system (DRVS) was the second step
– Data at our fingertips
• Organization, Center, and Provider level data
– Allowed us to map our exact workflow (how we document) to the reports
– Many reports available out of the box (over 65) which were in line with our reporting needs
– Upgrades and changes to the measure definitions are managed by Azara
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Let’s Stay Together: Strategic Alignment
• As a FQHC, we are always managing limited resources so we had to choose a few things to focus on from our exhaustive list:
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Key results
Quality turtle
Organization Dashboard
Quality Improvement
HbA1c
Paps
UDS
Meaningful Use
2yo Smoking
HEDIS
Imm
Provider Scorecards
Clinician Compensation Plan
Patient Centered Medical Home and direct patient care
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Alignment of Clinical Metrics
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Life is a Highway:
DRVS Implementation
• Features
– Primary implementation team: Health informatics team, two clinicians, performance improvement coordinator
– Each report tested by at least two team members
• 20 non‐compliant and 20 compliant
• Identified‐ mapping issues, definition issues
– Iterative process with Azara  Ongoing
– End‐user testing: clinicians, medical assistants
– Provider training/ re‐training
• How to use DRVS and where to document
– Support staff training
• Result
– Each report was the best that we could get it, and each of us involved had a better understanding of the report
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A Matter of Trust
Building trust in the data
– People working with the data trusted and understood the reports
• We recognized an issue as a report failure v. a user error – Ex: cervical cancer screening
• Physicians personally audited >10 key reports and vouched for them
– Performance improvement coordinator monitors this regularly
– The process of workflow documentation for each metric is both defined and documented
• Instructions/ user guide with screen shots provided by Azara
• Cheat sheets maintained by us
– If a provider doesn’t think their results are correct:
• Collect specific patient examples – Win‐Win opportunity: Get their buy‐in and/or improve our report!
– We walk them through a sample of patients so they understand
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Diabetic Control
HbA1c < 9 January 2012 – July 2014
70
70
60
50
AR
50
40
MX
40
Tier 3
January 2012‐ May 2013
Captured 5/2013
May‐13
Mar‐13
Jan‐13
Nov‐12
Sep‐12
Jul‐12
May‐12
Mar‐12
Jan‐12
0
10
0
October 2012‐ July 2014
Captured 7/2014
Jul‐14
Tier 1
Apr‐14
10
20
Jan‐14
HT
Oct‐13
20
30
Jul‐13
SA
Apr‐13
OS
30
Jan‐13
BE
Oct‐12
BMS
60
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Sugar, We’re Goin Down
• Hemoglobin A1c pitfalls and opportunities
– Multiple labs utilized by our system
– Test names can change or have many permutations impacting mapping. (Ex: Hgba1c. and HgbA1c)
– Labs on paper (from specialists, non‐interfaced labs) requires manual entry of lab results
• This also occurs with paper lab requisitions instead of CPOE
– Lab tracking and registries helps with building trust in the data
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Diabetes Registry
Unwritten:
Linking Documentation & Data
• Data mapping allows us to link our workflow as providers (what makes sense) to something concrete
– Multiple possible locations to document
– As few extra clicks as possible
• “If you didn’t document it, you didn’t do it”
– Get credit for the work that you do
– Standardization of documentation allows for accurate data capture and more representative quality metrics
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Weight Assessment, Counseling on Diet and Activity in Children
80%
70%
% Compliant
60%
50%
Monthly
Trailing Year
40%
30%
20%
10%
Documentation Provider
Comp Plan Training
Scorecard
Turtle Team
DRVS
0%
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Get Up, Get Into It, Get Involved (Pt 1):
Provider and Staff Engagement
• Provider scorecards
– Regular feedback
• DRVS put results (and the data to back it) at their fingertips
– Friendly competition
• Involvement in turtle teams (PDSA teams)
– Teaches how to do something about improving their scores
• Clinician compensation plan
– Productivity, quality, citizenship
– Show me the money
• Clinical support staff buy‐in
– MA audits
– MA PCMH incentive
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Provider Score Card
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Clinician Compensation Plan
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Breast Cancer Screening
60%
Monthly
50%
Trailing Year
% Compliant
40%
30%
Provider
Comp Plan Turtle Team
20%
10%
DRVS
0%
20
20
Depression Screening
100%
90%
Trailing Year
80%
Monthly
70%
60%
50%
40%
30%
MA Audits
PCMH MA incentive
20%
10%
0%
Dashboard
DRVS
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Keeps Gettin’ Better:
Process Improvement
PDSA is our primary process improvement method
– Used in our organization for PCMH/ NCQA, quality improvement, any reportable outcome
– Focused on tests of small incremental changes
• Need data to determine how we did and next steps – DRVS allows providers, managers, nurses, etc. to access the data for a single provider, group of providers or all providers
• For the specific time period they are measuring
– Registries and report details can help to provide the information to develop the next test of change
• Identify gaps and opportunities
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Asthma Action Plans in Children
70%
60%
Monthly
50%
Trailing Year
40%
30%
20%
Updated asthma toolkit
10%
0%
DRVS
Grant renewal;
Training, feedback; PDSA project
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Asthma Status and Management Registry
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Team:
Data Makes PCMH Possible
• Pre‐Visit Planning report
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Provided by administrative assistants
Utilized by medical assistants
Reviewed by providers and staff in huddles
This information is key to identifying opportunities to improve care and workflow with minimal added work
• Registries
– Supports ownership for a panel of patients and their health outcomes – Outcomes or opportunities can be identified outside of the context of a visit
– Better application of standing orders and outreach to meet outcomes
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Pre‐Visit Planning Report
8:00
8:15
Moderate Risk
Risk Factors: Tobacco Use
High Risk
Risk Factors: SMIP, SAD
8:45
9:00
Risk Factors: Pregnancy
Moderate Risk
Risk Factors: Obesity
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Diabetes Registry
2013 Quality Turtle Results
• One of four Key Results for the organization
• Presented to staff monthly
– Posted in centers, featured in the newsletter, discussed at staff meetings
• Turn our turtle green!
HbA1c
Paps
2yo Imm
Smoking
Calypso
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Quality Turtle Reporting
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Lessons Learned
• Keys to our success:
– Data validation was important to build trust
– Provider champions helped ease the way
– Training and re‐training (and a lot of patience)
• Providers, managers, clinical and admin support staff
• Teach them to fish
– Baby steps
• Continued providing paper scorecards with help of DRVS
• Anonymous reporting  Transparency
– Strategic alignment
• Focus on what people can handle • Can reduce friction, minimize wasted work, and create synergy!
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Questions?
The Playlist
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The Story‐ Brandi Carlile (Sara Ramirez)
The Beginning‐ John Legend
A Change is Gonna Come‐ Sam Cooke
On the Road Again‐ Willie Nelson
Let’s Stay Together‐ Al Green
Life is a Highway‐ Tom Cochrane
A Matter of Trust‐ Billy Joel
Sugar We are Goin’ Down‐ Fall Out Boy
Unwritten‐ Natasha Bedingfield
Get Up, Get Into It, Get Involved Pt. 1‐ James Brown
Keeps Getting’ Better‐ Christina Aguilera
Team‐ Lorde
Lessons Learned‐ Carrie Underwood